Provider Demographics
NPI:1447405006
Name:GILLER, IVY LISA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:IVY
Middle Name:LISA
Last Name:GILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2250
Mailing Address - Country:US
Mailing Address - Phone:516-625-5863
Mailing Address - Fax:516-484-0388
Practice Address - Street 1:153 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2250
Practice Address - Country:US
Practice Address - Phone:516-625-5863
Practice Address - Fax:516-484-0388
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO36057-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical